Drainage, fibrinolytics, or surgery: A comparison of treatment options in pediatric empyema

Robert L. Gates, Mark Hogan, Samuel Weinstein, Marjorie J. Arca

Research output: Contribution to journalArticle

86 Citations (Scopus)

Abstract

Background The current treatments of pediatric empyemas include tube thoracostomy with or without the instillation of fibrinolytics, video-assisted thoracoscopic surgery (VATS), and open thoracotomy with decortication. Whereas success has been reported for all of these techniques, VATS has been suggested as the best method because of decreased length of stay. Methods A chart review of children who presented with parapneumonic effusions from February 2000 to June 2002 was conducted. The patients were divided into 4 groups depending on the treatment received: group I, chest tube alone (n = 18); group II, chest tube and fibrinolytics (n = 24); group III, chest tube, fibrinolytic, and surgery (n = 5); and group IV, surgery alone (n = 6). Preadmission, in-hospital, and outcome variables for the groups were recorded and compared using the Kruskall-Wallis test, with a P value less than .05 considered significant. All the patients who received fibrinolytics (group II and III) were grouped into subjects who received immediate transpleural fibrinolytics versus those who received fibrinolytics 48 hours after chest tube insertion. Length of stay (LOS), need for surgery, and hospital costs were compared between the early and late fibrinolytic groups using the Wilcoxon rank-sum test, with a P value less than .05 considered significant. Results Comparison of duration of symptoms, duration of preadmit antibiotics, initial white blood cell count, total lymphocyte count, and antibiotics showed no significance among the 4 groups. When comparing outcome variables, the "nonsurgery groups" (groups I and II) had shorter LOS, intensive care unit stay, and hospital charges when compared with the "surgery groups" (groups III and IV). The timing of fibrinolytic instillation (immediate versus later) did not significantly affect in the LOS, hospital charges, or the tendency to need surgery eventually in the patients who received intrapleural fibrinolytics (group II and III combined). LOS was predicted by preadmit duration of symptoms (P = .025) and overall duration of fever (P < .01). The level of pleural glucose seemed to be predictive of need for surgery (P = .015). Overall, 11 of 54 children (20.2%) eventually needed surgery. Conclusions Tube drainage with intrapleural instillation of fibrinolytics can be performed successfully in a large number of children with empyemas. Ultrasound characterization of the fluid and, perhaps, glucose levels may guide surgical versus nonsurgical therapy. In centers in which percutaneous drainage and tissue plasminogen activator are available, this option may be a safe and less costly alternative to surgery.

Original languageEnglish (US)
Pages (from-to)1638-1642
Number of pages5
JournalJournal of Pediatric Surgery
Volume39
Issue number11
DOIs
StatePublished - Nov 2004
Externally publishedYes

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Empyema
Drainage
Pediatrics
Chest Tubes
Length of Stay
Hospital Charges
Video-Assisted Thoracic Surgery
Therapeutics
Nonparametric Statistics
Thoracostomy
Anti-Bacterial Agents
Glucose
Hospital Costs
Lymphocyte Count
Tissue Plasminogen Activator
Thoracotomy
Leukocyte Count
Intensive Care Units
Fever

Keywords

  • cost analysis
  • diagnostic ultrasound scan
  • Empyema
  • fibrinolytic therapy
  • thoracoscopy
  • thoracotomy

ASJC Scopus subject areas

  • Surgery

Cite this

Drainage, fibrinolytics, or surgery : A comparison of treatment options in pediatric empyema. / Gates, Robert L.; Hogan, Mark; Weinstein, Samuel; Arca, Marjorie J.

In: Journal of Pediatric Surgery, Vol. 39, No. 11, 11.2004, p. 1638-1642.

Research output: Contribution to journalArticle

Gates, Robert L. ; Hogan, Mark ; Weinstein, Samuel ; Arca, Marjorie J. / Drainage, fibrinolytics, or surgery : A comparison of treatment options in pediatric empyema. In: Journal of Pediatric Surgery. 2004 ; Vol. 39, No. 11. pp. 1638-1642.
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